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Doctors’ Notes: Guys, it’s time to talk about what’s below your belt

One in 250 boys is born with a condition called hypospadias, where the urethra opening is in the wrong spot. So why doesn’t anyone talk about it?

Researchers estimate that at least 10 to 20 per cent of men with hypospadias have a relative with the same condition. (dreamstime photo illustration)

By Dr. Walid A. FarhatBarbara NeilsonUniversity of Toronto

Mon., Jan. 23, 2017

Talking about the penis is one of the few remaining taboos in medicine. In urology, we have a saying: what’s below the waist is under the radar. And that silence is a shame because problems aren’t unusual.

The most common one, affecting one in 250 boys, occurs when the opening is not at the tip of the penis and the foreskin is incomplete.

In this condition, called hypospadias, the opening is usually elsewhere along the shaft of the penis, or very occasionally in the scrotum.

It’s more than a cosmetic problem: To avoid spraying on his feet, someone with uncorrected hypospadias must generally sit to urinate, causing uncomfortable questions for school-aged boys and men alike. In some cases, the penis, whether surgically corrected or not, also curves downward. In rare cases depending on the severity of the bend, this may interfere with sexual intercourse.

Teenagers with severe hypospadias express real emotional pain about their condition, and go to lengths to hide it from friends. Grown men recall the worst part about a childhood with an atypical penis was the isolation: nobody would discuss their problem, including parents and doctors. This increased their shame. Even the loss of a seemingly trivial rite of passage for a Canadian boy — “writing” his name in the snow — can make a child feel different.

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The problem can be much worse in some other cultures, where an atypical penis must be kept strictly secret or it will ruin siblings’ marriage chances. In some parts of the world, a boy or girl born with severe genital differences is considered not worthy of life.

Even in Canada, the chance of hypospadias is never discussed during prenatal classes that otherwise address birth issues like cleft lip and heart problems. Though it is a common pediatric problem, little research is done and there are no fundraisers for penile research. Parents worry their sons will be stigmatized and rejected, and don’t advertise the problem by discussing it with friends or relatives.

Researchers estimate that at least 10 to 20 per cent of men with hypospadias have a relative with the same condition. But this familial connection could be far higher for all we know. That’s one problem with the secrecy that surrounds a medical stigma: people don’t know if their relatives are also affected.

Hereditary issues aside, cases of hypospadias do seem to be increasing, and we aren’t sure why. There’s some evidence that pollution and other environmental factors are contributing. Pesticides and other chemicals are suspected because of their role in disrupting hormones responsible for forming the urethra, foreskin and genitalia.

The good news: most hypospadias cases are recognized quickly and easily at birth, and treated with surgery during the boy’s first year of life. But this condition can be difficult to correct if it’s very severe, requiring multiple surgeries. For this reason, it’s essential to support the family making the decision and the boys as they get older. There are online and in-person support groups. Families often need help feeling comfortable to talk openly of this difference.

Some parents are now considering deferring surgery until their son is old enough to decide for himself. While we support a parent’s decision either way, it’s important to realize that penile surgery may be more painful after infancy, when it’s more difficult to tolerate a catheter in the urethra or pain secondary to the surgery itself. As well, sometimes, a patient will return for additional surgery after he becomes sexually active, and wishes to further improve the appearance of his penis.

Because surgery can’t always fully correct the problem, it’s important for parents to help normalize atypical penises with their children. Men should occasionally sit on the toilet to urinate in front of sons with this issue — demonstrating that sitting down is not just for women and girls. And it’s important to address any shame that parents may feel about a son’s atypical penis, so that they don’t convey those feelings to him.

We look forward to a day when healthy communication replaces the silence and shame around this common and treatable problem.

Dr. Walid Farhat is a professor of Surgery and Urology at U of T’s Faculty of Medicine, and a Paediatric Urologist at The Hospital for Sick Children (SickKids). Barbara Neilson, MSW, RSW is a social worker in the Division of Urology at SickKids. Doctors’ Notes is a weekly column by members of the University of Toronto’s Faculty of Medicine. Email doctorsnotes@thestar.ca

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